Borderline Personality Disorder (BPD) Part III

 Medications

A 2010 Cochrane review found that no medications were effective for the core symptoms of BPD, such as chronic feelings of emptiness, identity disturbances, and fears of abandonment. Some medications might impact isolated symptoms of BPD or those of comorbid conditions. Later reviews in 2017 and 2020 confirmed these findings, with the latter noting a decline in research into medications for BPD treatment and mostly negative results. Quetiapine showed some benefits for BPD severity, psychosocial impairment, aggression, and manic symptoms at doses of 150 mg/day to 300 mg/day. Despite the lack of evidence, SSRIs are still frequently prescribed for BPD.

Specific medications have shown varied effectiveness on BPD symptoms: haloperidol and flupenthixol for anger and suicidal behavior reduction; aripiprazole for decreased impulsivity and interpersonal problems; and olanzapine and quetiapine for reducing affective instability, anger, and anxiety, though olanzapine showed less benefit for suicidal ideation than a placebo. Mood stabilizers like valproate and topiramate showed some improvements in depression, impulsivity, and anger, but the effect of carbamazepine was not significant. Of the antidepressants, amitriptyline may reduce depression, but mianserin, fluoxetine, fluvoxamine, and phenelzine sulfate showed no effect. Omega-3 fatty acid may ameliorate suicidality and improve depression. As of 2017, trials with these medications had not been replicated and the effect of long-term use had not been assessed. Lamotrigine and other medications like IV ketamine for unresponsive depression require further research for their effects on BPD.

Given the weak evidence and potential for serious side effects, the UK National Institute for Health and Clinical Excellence (NICE) recommends against using drugs specifically for BPD or its associated behaviors and symptoms. Medications may be considered for treating comorbid conditions within a broader treatment plan. Reviews suggest minimizing the use of medications for BPD to very low doses and short durations, emphasizing the need for careful evaluation and management of drug treatment in BPD.

Health care services

The disparity between those benefiting from treatment and those receiving it, known as the "treatment gap," arises from several factors. These include reluctance to seek treatment, healthcare providers' underdiagnosis, and limited availability and accessibility to advanced treatments. Furthermore, establishing clear pathways to services and medical care remains a challenge, complicating access to treatment for individuals with BPD. Despite efforts, many healthcare providers lack the training or resources to address severe BPD effectively, an issue acknowledged by both affected individuals and medical professionals.

 

In the context of psychiatric hospitalizations, individuals with BPD constitute approximately 20% of admissions. While many engage in outpatient treatment consistently over several years, reliance on more restrictive and expensive treatment options, such as inpatient admission tends to decrease over time.

Service experiences vary among individuals with BPD. Assessing suicide risk poses a challenge for clinicians, with patients underestimating the lethality of self-harm behaviors. The suicide risk among people with BPD is significantly higher than that of the general population, characterized by a history of multiple suicide attempts during crises. Notably, about half of all individuals who commit suicide are diagnosed with a personality disorder, with BPD being the most common association.

In 2014, following the death by suicide of a patient with BPD, the National Health Service (NHS) in England faced criticism from a coroner for the lack of commissioned services to support individuals with BPD. It was stated that 45% of female patients were diagnosed with BPD, yet there was no provision or prioritization for therapeutic psychological services. At that time, England had only 60 specialized inpatient beds for BPD patients, all located in London or the northeast region.

Prognosis

With treatment, the majority of people with BPD can find relief from distressing symptoms and achieve remission, defined as a consistent relief from symptoms for at least two years. A longitudinal study tracking the symptoms of people with BPD found that 34.5% achieved remission within two years from the beginning of the study. Within four years, 49.4% had achieved remission, and within six years, 68.6% had achieved remission. By the end of the study, 73.5% of participants were found to be in remission. Moreover, of those who achieved recovery from symptoms, only 5.9% experienced recurrences. A later study found that ten years from baseline (during a hospitalization), 86% of patients had sustained a stable recovery from symptoms. Other estimates have indicated an overall remission rate of 50% at 10 years, with 93% of people being able to achieve a 2 year remission and 86% achieving at least a 4 year remission. And a 30% risk of relapse over 10 years (relapse indicating a recurrence of BPD symptoms meeting diagnostic criteria). A meta-analysis which followed people over 5 years reported remission rates of 50-70%.

Patient personality can play an important role during the therapeutic process, leading to better clinical outcomes. Recent research has shown that BPD patients undergoing dialectical behavior therapy (DBT) exhibit better clinical outcomes correlated with higher levels of the trait of agreeableness in the patient, compared to patients either low in agreeableness or not being treated with DBT. This association was mediated through the strength of a working alliance between patient and therapist; that is, more agreeable patients developed stronger working alliances with their therapists, which in turn, led to better clinical outcomes.

In addition to recovering from distressing symptoms, people with BPD can also achieve high levels of psychosocial functioning. A longitudinal study tracking the social and work abilities of participants with BPD found that six years after diagnosis, 56% of participants had good function in work and social environments, compared to 26% of participants when they were first diagnosed. Vocational achievement was generally more limited, even compared to those with other personality disorders. However, those whose symptoms had remitted were significantly more likely to have good relationships with a romantic partner and at least one parent, good performance at work and school, a sustained work and school history, and good psychosocial functioning overall.

Epidemiology

BPD has a point prevalence of 1.6% and a lifetime prevalence of 5.9% of the global population. Within clinical settings, the occurrence of BPD is 6.4% among urban primary care patients, 9.3% among psychiatric outpatients, and approximately 20% among psychiatric inpatients. Despite the high utilization of healthcare resources by individuals with BPD, up to half may show significant improvement over a ten-year period with appropriate treatment.

Regarding gender distribution, women are diagnosed with BPD three times more frequently than men in clinical environments. Nonetheless, epidemiological research in the United States indicates no significant gender difference in the lifetime prevalence of BPD within the general population. This finding implies that women with BPD may be more inclined to seek treatment compared to men. Studies examining BPD patients have found no significant differences in the rates of childhood trauma and levels of current psychosocial functioning between genders. The relationship between BPD and ethnicity continues to be ambiguous, with divergent findings reported in the United States. The overall prevalence of BPD in the U.S. prison population is thought to be 17%. These high numbers may be related to the high frequency of substance use and substance use disorders among people with BPD, which is estimated at 38%.

History

Devaluation in Edvard Munch's Salome (1903). Idealization and devaluation of others in personal relations is a common trait in BPD. The painter Edvard Munch depicted his new friend, the violinist Eva Mudocci, in both ways within days. First as "a woman seen by a man in love", then as "a bloodthirsty and cannibalistic Salome". In modern times, Munch has been diagnosed as having had BPD.

The coexistence of intense, divergent moods within an individual was recognized by Homer, Hippocrates, and Aretaeus, the latter describing the vacillating presence of impulsive anger, melancholia, and mania within a single person. The concept was revived by Swiss physician Théophile Bonet in 1684 who, using the term folie maniaco-mélancolique, described the phenomenon of unstable moods that followed an unpredictable course. Other writers noted the same pattern, including the American psychiatrist Charles H. Hughes in 1884 and J. C. Rosse in 1890, who called the disorder "borderline insanity". In 1921, Emil Kraepelin identified an "excitable personality" that closely parallels the borderline features outlined in the current concept of BPD.

The idea that there were forms of disorder that were neither psychotic nor simply neurotic began to be discussed in psychoanalytic circles in the 1930s. The first formal definition of borderline disorder is widely acknowledged to have been written by Adolph Stern in 1938. He described a group of patients who he felt to be on the borderline between neurosis and psychosis, who very often came from family backgrounds marked by trauma. He argued that such patients would often need more active support than that provided by classical psychoanalytic techniques.

The 1960s and 1970s saw a shift from thinking of the condition as borderline schizophrenia to thinking of it as a borderline affective disorder (mood disorder), on the fringes of bipolar disorder, cyclothymia, and dysthymia. In the DSM-II, stressing the intensity and variability of moods, it was called cyclothymic personality (affective personality). While the term "borderline" was evolving to refer to a distinct category of disorder, psychoanalysts such as Otto Kernberg were using it to refer to a broad spectrum of issues, describing an intermediate level of personality organization between neurosis and psychosis.

After standardized criteria were developed to distinguish it from mood disorders and other Axis I disorders, BPD became a personality disorder diagnosis in 1980 with the publication of the DSM-III. The diagnosis was distinguished from sub-syndromal schizophrenia, which was termed "schizotypal personality disorder". The DSM-IV Axis II Work Group of the American Psychiatric Association finally decided on the name "borderline personality disorder", which is still in use by the DSM-5. However, the term "borderline" has been described as uniquely inadequate for describing the symptoms characteristic of this disorder.

Etymology

Earlier versions of the DSM—before the multiaxial diagnosis system—classified most people with mental health problems into two categories: the psychotics and the neurotics. Clinicians noted a certain class of neurotics who, when in crisis, appeared to straddle the borderline into psychosis. The term "borderline personality disorder" was coined in American psychiatry in the 1960s. It became the preferred term over a number of competing names, such as "emotionally unstable character disorder" and "borderline schizophrenia" during the 1970s. Borderline personality disorder was included in DSM-III (1980) despite not being universally recognized as a valid diagnosis.

Controversies

Credibility and validity of testimony

The credibility of individuals with personality disorders has been questioned at least since the 1960s.  Two concerns are the incidence of dissociation episodes among people with BPD and the belief that lying is not uncommon in those diagnosed with the condition.

Dissociation

Researchers disagree about whether dissociation, or a sense of emotional detachment and physical experiences, impacts the ability of people with BPD to recall the specifics of past events. A 1999 study reported that the specificity of autobiographical memory was decreased in BPD patients. The researchers found that decreased ability to recall specifics was correlated with patients' levels of dissociation, which 'may help them to avoid episodic information that would evoke acutely negative affect'.

Gender

In a clinic, up to 80% of patients are women, but this might not necessarily reflect the gender distribution in the entire population. According to Joel Paris, the primary reason for gender disparities in clinical settings is that women are more likely to develop symptoms that prompt them to seek help. Statistics indicate that twice as many women as men in the community experience depression. Conversely, men more frequently meet criteria for substance use disorder and psychopathy, but tend not to seek treatment as often. Additionally, men and women with similar symptoms may manifest them differently. Men often exhibit behaviors such as increased alcohol consumption and criminal activity, while women may internalize anger, leading to conditions like depression and self-harm, such as cutting or overdosing. Hence, the gender gap observed in antisocial personality disorder and borderline personality disorder, which may share similar underlying pathologies but present different symptoms influenced by gender. In a study examining completed suicides among individuals aged 18 to 35, 30% of the suicides were attributed to people with BPD, with a majority being men and almost none receiving treatment. Similar findings were reported in another study.

In short, men are less likely to seek or accept appropriate treatment, more likely to be treated for symptoms of BPD such as substance use rather than BPD itself (the symptoms of BPD and ASPD possibly deriving from a similar underlying etiology); more likely to wind up in the correctional system due to criminal behavior; and, more likely to commit suicide prior to diagnosis.

Among men diagnosed with BPD there is also evidence of a higher suicide rate: "men are more than twice as likely as women—18 percent versus 8 percent"—to die by suicide.

There are also sex differences in borderline personality disorder. Men with BPD are more likely to recreationally use substances, have explosive temper, high levels of novelty seeking and have (especially) antisocial, narcissistic, passive-aggressive or sadistic personality traits (male BPD being characterised by antisocial overtones). Women with BPD are more likely to have eating disorders, mood disorders, anxiety and post-traumatic stress.

Manipulative behavior

Manipulative behavior to obtain nurturance is considered by the DSM-IV-TR and many mental health professionals to be a defining characteristic of borderline personality disorder. In one research study, 88% of therapists reported that they have experienced manipulation attempts from patient(s). Marsha Linehan has argued that doing so relies upon the assumption that people with BPD who communicate intense pain, or who engage in self-harm and suicidal behavior, do so with the intention of influencing the behavior of others. The impact of such behavior on others—often an intense emotional reaction in concerned friends, family members, and therapists—is thus assumed to have been the person's intention.

According to Linehan, their frequent expressions of intense pain, self-harming, or suicidal behavior may instead represent a method of mood regulation or an escape mechanism from situations that feel unbearable, however, making their assumed manipulative behavior an involuntary and unintentional response.

One paper identified possible reasons for manipulation in BPD: identifying others feelings and reactions, a regulatory function due to insecurity, to communicate ones emotions and connect to others, or to feel as if one is in control, or to allow them to be "liberated" from relationships or commitments.

Stigma

The features of BPD include: emotional instability, intense and unstable interpersonal relationships, a need for intimacy, and a fear of rejection. As a result, people with BPD often evoke intense emotions in those around them. Pejorative terms to describe people with BPD, such as "difficult", "treatment resistant", "manipulative", "demanding", and "attention seeking", are often used and may become a self-fulfilling prophecy, as negative treatment of these individuals may trigger further self-destructive behavior.

Since BPD can be a stigmatizing diagnosis even within the mental health community, some survivors of childhood abuse who are diagnosed with BPD are re-traumatized by the negative responses they receive from healthcare providers. One camp argues that it would be better to diagnose these people with post-traumatic stress disorder, as this would acknowledge the impact of abuse on their behavior. Critics of the PTSD diagnosis argue that it medicalizes abuse rather than addressing the root causes in society. Regardless, a diagnosis of PTSD does not encompass all aspects of the disorder.

Physical violence

The stigma surrounding borderline personality disorder includes the belief that people with BPD are prone to violence toward others. While movies and visual media often sensationalize people with BPD by portraying them as violent, the majority of researchers agree that people with BPD are unlikely to physically harm others. Although people with BPD often struggle with experiences of intense anger, a defining characteristic of BPD is that they direct it inward toward themselves.

One 2020 study found that BPD is individually associated with psychological, physical and sexual forms of intimate partner violence (IPV), especially amongst men. In terms of the AMPD trait facets, hostility (negative affectivity), suspiciousness (negative affectivity) and risk taking (disinhibition) were most strongly associated with IPV perpetration for the total sample.

In addition, adults with BPD have often experienced abuse in childhood; so many people with BPD adopt a "no-tolerance" policy toward expressions of anger of any kind. Their extreme aversion to violence can cause many people with BPD to overcompensate and experience difficulties being assertive and expressing their needs. This is one reason why people with BPD often choose to harm themselves over potentially causing harm to others.

Mental health care providers

People with BPD are considered to be among the most challenging groups of patients to work with in therapy, requiring a high level of skill and training for the psychiatrists, therapists, and nurses involved in their treatment. A majority of psychiatric staff report finding individuals with BPD moderately to extremely difficult to work with and more difficult than other client groups. This largely negative view of BPD can result in people with BPD being terminated from treatment early, being provided harmful treatment, not being informed of their diagnosis of BPD, or being misdiagnosed. With healthcare providers contributing to the stigma of a BPD diagnosis, seeking treatment can often result in the perpetuation of BPD features. Efforts are ongoing to improve public and staff attitudes toward people with BPD.

In psychoanalytic theory, the stigmatization among mental health care providers may be thought to reflect countertransference (when a therapist projects his or her own feelings on to a client). This inadvertent countertransference can give rise to inappropriate clinical responses, including excessive use of medication, inappropriate mothering, and punitive use of limit setting and interpretation.

Some clients feel the diagnosis is helpful, allowing them to understand that they are not alone and to connect with others with BPD who has developed helpful coping mechanisms. However, others experience the term "borderline personality disorder" as a pejorative label rather than an informative diagnosis. They report concerns that their self-destructive behavior is incorrectly perceived as manipulative and that the stigma surrounding this disorder limits their access to health care. Indeed, mental health professionals frequently refuse to provide services to those who have received a BPD diagnosis.

Terminology

Because of concerns around stigma, and because of a move away from the original theoretical basis for the term (see history), there is ongoing debate about renaming borderline personality disorder. While some clinicians agree with the current name, others argue that it should be changed, since many who are labelled with borderline personality disorder find the name unhelpful, stigmatizing, or inaccurate. Valerie Porr, president of Treatment and Research Advancement Association for Personality Disorders states that "the name BPD is confusing, imparts no relevant or descriptive information, and reinforces existing stigma".

Alternative suggestions for names include emotional regulation disorder or emotional dysregulation disorder. Impulse disorder and interpersonal regulatory disorder are other valid alternatives, according to John G. Gunderson of McLean Hospital in the United States. Another term suggested by psychiatrist Carolyn Quadrio is post traumatic personality disorganization (PTPD), reflecting the condition's status as (often) both a form of chronic post-traumatic stress disorder (PTSD) as well as a personality disorder. However, although many with BPD do have traumatic histories, some do not report any kind of traumatic event, which suggests that BPD is not necessarily a trauma spectrum disorder.

The Treatment and Research Advancements National Association for Personality Disorders (TARA-APD) campaigned unsuccessfully to change the name and designation of BPD in DSM-5, published in May 2013, in which the name "borderline personality disorder" remains unchanged and it is not considered a trauma- and stressor-related disorder.

Society and culture

Literature

In literature, characters believed to exhibit signs of BPD include Catherine in Wuthering Heights (1847), Smerdyakov in The Brothers Karamazov (1880), and Harry Haller in Steppenwolf (1927).

Film

Films have also attempted to portray BPD, with characters in Margot at the Wedding (2007), Mr. Nobody (2009), Cracks (2009), Truth (2013), Wounded (2013), Welcome to Me (2014), and Tamasha (2015) all suggested to show traits of the disorder. The behavior of Theresa Dunn in Looking for Mr. Goodbar (1975) is consistent with BPD, as suggested by Robert O. Friedel. Films like Play Misty for Me (1971) and Girl, Interrupted (1999, based on the memoir of the same name) suggest emotional instability characteristic of BPD, while Single White Female (1992) highlights aspects such as identity disturbance and fear of abandonment.  Clementine in Eternal Sunshine of the Spotless Mind (2004) is noted to show classic BPD behavior, and Carey Mulligan's portrayal in Shame (2011) is praised for its accuracy regarding BPD characteristics by psychiatrists.

Psychiatrists have even analyzed characters such as Kylo Ren and Anakin Skywalker/Darth Vader from the Star Wars films, noting that they meet several diagnostic criteria for BPD.

Television

Television series like Crazy Ex-Girlfriend (2015) and the miniseries Maniac (2018) depict characters with BPD. Traits of BPD and narcissistic personality disorders are observed in characters like Cersei and Jaime Lannister from A Song of Ice and Fire (1996) and its TV adaptation Game of Thrones (2011). In The Sopranos (1999), Livia Soprano is diagnosed with BPD, and even the portrayal of Bruce Wayne/Batman in the show Titans (2018) is said to include aspects of the disorder. The animated series Bojack Horseman (2014) also features a main character with symptoms of BPD.

Awareness

Awareness of BPD has been growing, with the U.S. House of Representatives declaring May as Borderline Personality Disorder Awareness Month in 2008. People with BPD will share their personal experiences of living with the disorder on social media to raise awareness of the condition.

Public figures like South Korean singer-songwriter Lee Sun-mi have opened up about their personal experiences with the disorder, bringing further attention to its impact on individuals' lives.